A 57-year-old man with a diagnosis of idiopathic dilated cardiomyopathy was admitted for elective implantation of the HeartWare HVAD left ventricular assist device as a bridge to transplant. He was referred to our heart failure service in 2010 because of severe left ventricular dysfunction. Medical treatment with beta-blockers, an angiotensin-converting enzyme inhibitor, and aldosterone antagonists was optimized at that time. Due to severe functional mitral regurgitation and clinical worsening, the patient underwent MitraClip implantation (Figure, arrow) in March 2012 with excellent clinical response. An implantable cardioverter-defibrillator with cardiac resynchronization therapy (Figure, asterisk) was implanted in January 2015 after he developed complete left bundle branch block. He remained in New York Heart Association class II until February 2016 when he was admitted because of worsening heart failure. The patient was assessed for transplant and entered on the waiting list. Despite several admissions for levosimendan infusions, he remained in functional class IIIB and INTERMACS 4 profile level with a slow and progressive clinical decline. For that reason, a ventricular assist device (Figure, plus sign) was implanted as a bridge to transplant in June 2016. The following image shows these 3 devices in 1 patient, as a picture of how technology is changing the management of advanced heart failure.

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